Medical History Questionnaire

Medical History Questionnaire

This Medical History Questionnaire, Registration Form, Membership Application, Liability Release Form. Fast Start Assessment and bootcamp payment must be completed before the registration process can be considered complete and boot camp can begin.

It is wise to seek your doctor’s advice BEFORE beginning any health/fitness/nutrition program!

Registration Form

Membership Application

Liability Release Form

Fast Start Assessment Form

JOIN NOW!

* Required fields
Name *
E-mail Address *
Cell Phone *
Are you allergic to any medication? *
Do you take any medication on a regular or semi-regular basis? *
Do you have seizure disorder (epilepsy)? *
Do you have Type I or Type II Diabetes? *
Have you ever been diagnosed with anemia? *
Do you have high blood pressure? *
Do you have or have you ever had Heart Disease? *
Do you have or have you ever had Lung Disease? *
Do you have or have you ever had Liver Disease? *
Do you have or have you ever had Kidney Disease? *
Do you have or ever had asthma? *
Do you have or have you ever had a severe neck injury? *
Have you ever been rendered unconscious? *
Do you wear contact lenses or glasses? *
Have you ever injured your back? *
Do you have back pain? If yes, how often? *	Almost never Seldom Occasionally Frequently with vigorous exercise
Have you had a broken bone or fracture in past 2 years? *
Have you ever had knee pain in the past 2 years that has disabled you for more than a week? *
Do you have any physical conditions that cause pain? *
Have you had any surgical procedures? *
Have you ever had your body fat tested? *
Are you training for a specific event? *
If you answered yes to any questions, please explain here.
I have read and agree to the Privacy Policy *

Registration Form

Membership Application

Liability Release Form

JOIN NOW!

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Contact: The Freedom Coach

email: freedombyfitness@gmail.com

phone: 708-704-7309, 708-596-8728

fax: 708-596-8720